The highest level of comprehensive diagnosis and care for urologic disorders and diseases. For over 30 years, our Board Certified specialists have treated adult and pediatric urology patients in clinical centers in Joliet, New Lenox and Morris Illinois.

Bladder Health Questionnaire

Bladder Health Questionnaire

Please take a few seconds to answer the questions below about bladder health. Your cooperation is strictly voluntary. We will not record or save any unique identifier. All answers will be kept confidential. A third party may be used to collate and report data from your responses.

Age*

Gender*

Male

Female

1) During the last 3 months, have you leaked urine (even a small amount)?*

Yes

No

2) During the last 3 months, did you leak urine:

When you were performing some physical activity such as coughing, sneezing, lifting, or exercise?

When you had the urge or the feeling that you needed to empty your bladder, but could not reach the toilet fast enough?

Without physical activity and without a sense of urgency?

Select all that apply

3) During the last 3 months, did you leak urine most often:

When you were performing some physical activity such as coughing, sneezing, lifting, or exercise?

When you had the urge or the feeling that you needed to empty your bladder but could not get to the toilet fast enough?

Without physical activity and without a sense of urgency?

About equally as often with physical activity as with a sense of urgency?

Types of urinary incontinence are based on responses to question 3:

Response to Question 3

Most often with physical activity Type of Incontinence: Stress only or stress predominant

Most often with the urge to empty your bladder Type of Incontinence: Urge only or urge-predominant

Without physical activity or sense of urgency Type of Incontinence: Other cause only or other cause predominant

About equally with physical activity and sense of urgency Type of Incontinence: Mixed

Would you like to be contacted by our OAB Team to discuss treatment options?